Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

MAR 25 2022

ADMINISTRATIVE ORDER
No. 2022-_()0I0

SUBJECT: Guidelines on Tuberculosis - Human Immunodeficiency Virus

(TB-HIV) Services Integration for Universal Health Care (UHC)
Implementation

I. RATIONALE

The collaborative approach of prevention and control of Tuberculosis (TB)

and Human Immunodeficiency Virus (HIV) of the Department of Health (DOH) was
catalyzed with the issuance of Administrative Order (AQ) No. 2008-0022, entitled
“Policies and Guidelines in the Collaborative Approach of TB and HIV Prevention
and Control” and its further revision through AO No. 2014-0005. With the enactment
of Republic Act (RA) No. 11223 or the Universal Health Care (UHC) Act, TB and
HIV are identified as flagship programs for
integration in the UHC implementation.

The Philippine Health Sector HIV Strategic Plan 2020-2022 enumerates high
impact prevention, testing, treatment, and adherence strategies targeting high risk key
populations in high burden areas. Innovative and differentiated approaches for HIV
treatment and adherence involve introducing safer treatment regimen, managing
co-infections such as TB, enhancing case management, and scaling up viral load
testing.

Similarly, the updated Philippine Strategic TB Elimination Plan 2020-2023

(PhilSTEP1) enumerates the strategies for screening, testing and diagnosis, treatment,
and prevention that will contribute to the Global End TB objectives. Part of these
strategies are integrated patient-centered care including TB-HIV collaboration.

This policy consolidates the key components of the above strategies and
guidelines pertaining to TB and HIV with the goal of reducing the burden of TB
among people living with HIV (PLHIV) and the burden of HIV among people with
TB towards the attainment of goals of the UHC Act and FOURmula One Plus for
Health (F1 Plus).

Il. OBJECTIVE

This Order is issued to provide standards and mechanisms for collaboration

between the National TB Control Program (NTP) and National AIDS and STI
Prevention and Control Program (NASPCP) for the provision of TB and HIV services
under UHC.

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Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1192, 1113

Direct Line: 711-9502; 711-9503 Fax: 743-1829 ¢ URL: http://www.doh. gov. ph: email: ftduque@dbh.gov.ph
JI. ‘SCOPE OF APPLICATION

These guidelines shall apply to all public and private health facilities
providing TB and HIV services from screening, diagnosis, treatment, and prevention.
In the case of the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM),
the adoption of these guidelines shall be in accordance with RA No. 11054
(Bangsamoro Organic Law) and the subsequent laws and issuances to
be issued by the
Bangsamoro government.

Iv. DEFINITION OF TERMS

A. Active drug safety monitoring and management (aDSM) -

refers to the
reporting of all serious adverse events (SAE) and adverse events of special
interests (AEST) among patients using new drugs and new treatment regimen.

B. Antiretroviral therapy (ART) — refers to lifelong treatment using a combination

of three or more anti-retroviral (ARV) drugs to achieve viral suppression.

C. Nucleic acid amplification test (NAAT) - (e.g. GeneXpert test) refers to a

semi-automated, molecular assay which permits rapid diagnosis through the
detection of nucleic acid (DNA/RNA). It is used to detect TB, COVID, and other
infectious diseases as well as determine the viral load among PLHIV.

D. Community-based treatment -refers to taking the TB medications in a

designated location in the community, usually near the patient’s residence, with a
health worker or community volunteer acting as treatment supporter.

E. Digital adherence technologies — refer to tools designed to support people with

TB that allow them to take their medications at a place and time that is convenient
to them, while remaining connected to their health care provider.

F. Health facilities — refer to an institution that has health care as its core service,
function or business. Health care pertains to the maintenance or improvement of
the health of individuals or populations through the prevention, diagnosis,
treatment, rehabilitation and chronic management of disease, illness, injury and
other physical and mental ailments or impairments of human beings.

G. HIV testing — refers to any procedure used to identify the presence or absence of
HIV in a person’s body which includes a test for triage or HIV screening,
laboratory-based or facility-based testing, mobile procedures, and other
approaches.

H. HIV testing services — refer to a broad range of services that shall be provided
alongside HIV testing. These services include counseling, linkage to necessary
and appropriate HIV prevention, treatment and care, and other clinical support
services, as well as coordination with stakeholders to support quality assurance.
 Home-based treatment — refers to taking the TB medications at home assisted by
or
a family treatment supporter using digital adherence technologies.

Key populations — refer to populations with high risk of contracting HIV but not

limited to males who have sex with males, transgender women, people with
multiple sexual partners, and people who inject drugs.

Patient-centered care — refers to an approach to care that recognizes and respects

the patient’s rights and values, and considers the patient as an important partner
who actively participates in decisions on diagnosis and treatment.

Differentiated service delivery — refers to a person-centered approach that

simplifies and adapts HIV services across the cascade to reflect the preferences
and expectations of various groups of PLHIV while reducing unnecessary burdens
on the health system.

. TB preventive treatment (TPT) — refers to treatment offered to individuals who

are at risk of developing active TB disease to reduce that risk.

TB screening — refers to the systematic identification of presumptive TB in a

predetermined target group, using examinations or other procedures that can be
applied rapidly.

Young key populations — refer to populations within the age range of 15-24 years
old with high risk of contracting HIV but not limited to males who have sex with
males, people with multiple sexual partners, and people who inject drugs.

Vv. GENERAL GUIDELINES

A. Health facilities shall provide integrated TB and HIV services

to all patients and
ensure appropriate referral of cases within the health care provider network
(ACPN).

The DOH and local government units (LGUs) shall ensure adequate commodities
for the provision of TB-HIV services.

Resources from the national and local government, private sector, and partners
shall be pooled and harmonized through the Special Health Fund to ensure
efficient budgeting and to minimize catastrophic costs to patients and to avoid
overlapping of provision of services and proper role delineation.

Health care workers shall be capacitated to provide both TB and HIV services
according to standards.

Appropriate and timely TB and HIV treatment shall be given to all newly
diagnosed TB or HIV patients.
A Data Sharing Agreement shall be issued to ensure that data captured on
information systems related to TB and HIV will be rationally shared to better

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 manage both programs while maintaining confidentiality and security of data as
required by RA No. 10173 or the Data Privacy Act of 2012.

G. Infection prevention and control measures shall be strictly observed in the

delivery of TB and HIV services.

VI. SPECIFIC GUIDELINES

A. Prevention
1. All PLHIV who do not have active TB shall receive TB preventive treatment.
2. All household and close contacts of diagnosed TB cases in whom TB has been
ruled out shall be assessed for eligibility to TPT. TPT shall be offered for those
found eligible. Please refer to the NIP Manual of Procedures (MOP), 6th Ed.
(2020), page 70 Table 29 for TPT regimens, which can be accessed through
https://tinyurl.com/NTPMOP-6th.
Education, counseling, and social communication on TB and HIV prevention
shall be provided as part of the comprehensive care.
HIV prevention commodities such as condoms and lubricants shall be
appropriately provided to TB and HIV patients.
Existing service delivery networks shall be maximized for advocacy, demand
generation, service delivery, and implementation of other TB-HIV related
activities.

B. Detection
i. Early identification of TB among PLHIV shall be done through careful
assessment of signs and symptoms (fever, weight loss, cough, night sweats) at
every visit and by doing chest X-ray upon diagnosis of HIV and at least
annually. GeneXpert testing shall be done anytime a patient has TB signs and
symptoms or chest X-ray findings suggestive of TB. Please refer to the NTP
MOP, page 12 Figure 2, which can be accessed through
https://tinyurl.com/NTPMOP-6th.
All patients consulting the health facility shall also be screened for TB
according to algorithms in the NTP MOP, page 12 Figure 1, which can be
accessed through https://tinyurl.com/NTPMOP-6th.
All TB patients aged at least 15 years old shall be offered HIV testing
services.
The NAAT/GeneXpert shall be used as a primary diagnostic tool for diagnosis
of TB among presumptive TB and also for point-of-care HIV viral load testing
for PLHIV on Antiretroviral Therapy (ART).
A laboratory network analysis for TB and HIV shall be implemented to
determine the optimal number and location of required NAAT machines based
on testing targets and population served.
The LGUs shall coordinate with the Centers for Health Development (CHDs)
to ensure that the recommended laboratory sites for both TB and HIV are
within the regional laboratory network and referral system among laboratories
in the HCPNin their respective regions.

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 7. Existing specimen transport systems shall be optimized for both TB (sputum)
and HIV viral load testing (blood), and shail also be utilized for transport of
the results.
All public and private providers are mandated to report to the DOH all
diagnosed TB and HIV patients using available platforms (e.g., Integrated TB
Information System or ITIS, and One HIV, AIDS, and STI Information
System or OHASIS) as part of strengthening disease surveillance.

C. Infection Prevention and Control

i. Minimum public health standards shall be implemented in
all health facilities.
2. All health facilities providing TB and HIV services shall implement
administrative controls, engineering controls and use of personal protective
equipment based on facility risk assessment.

D. Treatment
1. Standard regimens for drug-susceptible and drug-resistant TB shall be used
based on eligibility criteria. Please refer to the NTP MOP, page 35 Figure 6
and page 45 Table 18, which can be accessed through
https:/Ainyurl.com/NTPMOP-6th.
Antiretroviral therapy (ART) shall be initiated within the same day upon
recognition of HIV infection, whenever possible, regardless of clinical and
immunologic status.
Persons with TB-HIV co-infection shall be given both TB and HIV treatment
based on DOH guidelines.
Patients with TB-HIV co-infection shall also be managed for prevention of
other opportunistic infections (Ols). For the list of Ols, please refer to the
DOH Department Memorandum (DM) No. 2020-0338, entitled “Adoption of
PSMID Clinical Practice Guidelines on the Prevention, Diagnosis and
Treatment of Opportunistic Infections in HIV Infected Adults and Adolescents
in the Philippines”, which can be accessed through
https://tinyurl.com/OI-Guidelines,
. Treatment adherence support and counseling shall be given to all patients with
TB, HIV, and TB-HIV co-infection.
Patient-centered care and differentiated service delivery through home-based
and community-based treatment shall be practiced.
When available, digital adherence technologies shall be used.
Active drug safety monitoring and management (aDSM) shall be implemented
for novel drugs and treatment regimens by reporting severe adverse events
(SAE) and adverse events of special interest (AESI).

E. Provision of Commodities

The DOH and LGUs shall ensure adequate commodities for the provision of
TB-HIV services.
1. The following commodities shall be procured by the DOH-Disease Prevention
and Control Bureau and transitioned to the LGUs based on the DOH-approved
Devolution Transition Plan as aligned with the UHC:

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 a. Cartridges for Xpert TB test
b. HIV point of care Viral Load (VL) cartridges
c. HIV testing kits
d. CD4 cartridges
e. First-line anti-TB drugs for drug-susceptible TB for adults, and children
f. Selected second line anti-TB drugs for drug resistant TB (Bedaquiline and
delamanid). Other second line anti-TB drugs will be provided by the
Global Fund. As part of the sustainability measure, the government will
continuously increase its commitment to provide these commodities
annually.
g./ Drugs for antiretroviral therapy (ART)
h. Drugs for TB preventive treatment
i. Isoniazid for 6 months (6H)
ii. Isoniazid+Rifampicin combination for 3 months (3HR)
iii. Isoniazid+Rifapentine combination for 12 weekly doses (3HP)
iv. Rifampicin for 4 months (4R)
i. Trimethoprim-Sulfamethoxazole (Cotrimoxazole) for prophylaxis or
treatment of Pneumocystis pneumonia
j. Azithromycin for Mycobacterium avium complex prophylaxis (Note: for
devolution in 2023)
k. Condoms and lubricants
= Personal protective equipment (PPE)

2. LGUs shall be responsible for providing or procuring the following:

oS
Chest X-ray for TB screening (provision
Specimen containers (sputum cups and
or
blood
referral)
collection vials)
Glass slides
po
Staining kits for direct sputum smear microscopy
Purified protein derivative (for Tuberculin skin test)
ho
Cartridges for Xpert TB test (augmentation)
testing kits (augmentation)
HIV

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HIV point of care VL cartridges (augmentation)
CD4 cartridges (augmentation)
co
Azithromycin for Mycobacterium avium complex prophylaxis (Note: for
devolution in 2023)
Condoms and lubricants (augmentation)
mr
PPE (augmentation)

3. Health facilities through Philhealth Outpatient HIV/AIDS Treatment (OHAT)

package
a. Consumables for HIV VL testing (EDTA tubes, cryovials)
b. Point of care HIV VL cartridges
c. CD4 cartridges

F. Capacity Building
1. Health workers in hospitals, health centers/rural health units, TB facilities, and
HIV treatment facilities including barangay health workers and community
volunteers shall be trained in TB and HIV care, particularly on the following:

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 NTP Manual of Procedures, 6th Ed.
FS
HIV counseling, testing, and treatment
Use of GeneXpert for TB diagnosis and HIV viral load testing
Bo
Integrated TB Information System (ITIS) and One HIV, AIDs, and STI
Information System (OHASIS)
e. Procurement and supply management

VII. MONITORING AND EVALUATION

A. Standard indicators shall be used to monitor TB and HIV program performance:

No. of TB patients with known HIV status (tested for HIV)
WN
No. of PLHIV screened for TB
No. ofpatients with TB-HIV co-infection
wk
No. of PLHIV given TB preventive treatment
Treatment outcome of patients placed on TB treatment and TB preventive
treatment

B. Other TB and HIV indicators not directly related to TB-HIV integration shall
continue to be monitored.

C. Data for the standard indicators shall be reported by all health facilities following
regular program reporting through ITIS and OHASIS.

D. Data sharing between ITIS and OHASIS shall be implemented for harmonization
of TB-HIV indicators.

E. Integrated monitoring and program implementation reviews shall be done for both
TB and HIV.

F. The TB-HIV Integration Technical working group shall convene to monitor

program implementation and perform other functions as stated in DOH AO No.
2014-0005.

VIII. ROLES AND RESPONSIBILITIES

A. The Disease Prevention and Control Bureau (DPCB) shall:

1. Develop the plan for implementation of the TB-HIV integration.
2. Ensure adequate commodities for TB and HIV.
3. Develop capacity-building tools for TB-HIV integration.
4. Provide technical assistance to CHDs in implementation of the TB-HIV
integration guidelines.
5. Monitor and evaluate implementation of TB-HIV service integration, and
provide regular feedback to the Public Health Services Team (PHST).
6. Develop additional policies and guidelines, as necessary.

B. The Epidemiclogy Bureau (EB) shall:

1. Maintain and update surveillance systems that capture TB-HIV data and
monitor TB-HIV indicators.

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 2. Collect and validate required data from facilities providing HIV services.
3. Provide monthly updates on TB-HIV-related strategic information to the
DPCB, partners, and other key stakeholders.
4. Develop and maintain the OHASIS and ensure availability to its end users.
“ Maintain the electronic recording and reporting system of HIV including
providers and facilities databases.

The Health Promotion Bureau (HPB) shall:

as
.

1. Ensure the promotion of the integrated TB-HIV part of the DOH Campaign
for Primary Care such as KosulTayo, and in coordination with the Presidential
Communications Operations Office (PCOO) for information dissemination.
2. Develop social behavior change communication (SBCC) plan and its
corresponding materials in different platforms.
w Monitor the implementation of the SBCC.
4. Evaluate the impact of the integrated TB-HIV SBCC
population.
to targeted individuals /

. The Knowledge Management and Information Technology Service (KMITS)

shall:
1. Develop and maintain the Integrated TB Information System (ITIS) and

ensure availability to its end users.

2. Maintain the electronic recording and reporting system of TB including
providers and facilities databases.
3. Ensure data privacy of patient’s personal information.

. The Centers fer Health Development (CHDs) and Ministry of Health -

Bangsamoro Autonomous Region in Muslim Mindanao (MOH-BARMM)
shall:
1. Lead capacity building of LGU health facilities in TB-HIV integration
2. Coordinate with LGUs in the distribution and procurement of necessary
commodities for implementation.
3. Collaborate with LGUs to develop the referral system for the TB and HIV
laboratory network including, but not limited to the referral procedure for HIV
VL
testing.
-

4. Provide technical assistance to LGUs and facilities, both public and private, in
the implementation of the guidelines.
w Monitor and evaluate implementation.
6. Provide feedback and quarterly program reports to DPCB to guide policy
revision or development.

. The Local Government Units (Provincial, City, and Municipal Levels) shall:
1. Co-lead in capacity-building activities related to TB and HIV and procurement
and supply management.
2. Implement the guidelines on TB and HIV integration.
Ww

Implement awareness and demand generation activities at the local level.

4. Establish the referral system including, but not limited to a laboratory
network.
5. Ensure adequate supply of commodities for TB-HIV.
 6. Provide feedback and quarterly program reports to CHDs and participate in
monitoring and review activities.
7. Provide and ensure access to transport mechanisms for patients.

G. The health facilities shall:

1. Provide TB and HIV services in accordance with DOH guidelines.
2. Ensure mechanisms and standards are in place for provision of TB and HIV
services.

H. Reference laboratories
L. The Research Institute for Tropical Medicine - National Tuberculosis
Reference Laboratory (RITM-NTRL) shall:
a. Provide technical guidance on CBNAAT machine (e.g. GeneXpert)
placement, installation, capacity building and operations.
b. Monitor and provide recommendations on operation of GeneXpert
laboratory.
c. Conduct EQA in
the use of CBNAAT.
d. Conduct Training of Trainers for the use of CBNAAT.

The National Reference Laboratory - San Lazaro Hespital STD AIDS

Cooperative Central Laboratory (NRL-SLH / SACCL) shall:
a. Provide External Quality Assessment Schemes (EQAS) for Serology to
HIV testing facilities and GeneXpert sites performing HIV Viral Load
testing.
b. Conduct of Training of Trainer of the Regional HIV-TB Coordinators on
Laboratory Quality Management System, Referral Networking and
Monitoring and Evaluation.
c. Conduct Kit Evaluation for the registration of test kits to be used in the
HIV testing facilities.
d. Resolve laboratory discrepancies and concerns regarding HIV testing.

I. Non-government / community-based
/civil society organizations shall:
> Advocate for political support and resource mobilization for TB-HIV program.
Provide support to patients in detection and treatment for both TB and HIV.
Provide support to LGUs
WRWN in
terms of TB and HIV awareness.
Actively engage in community-led monitoring of TB-HIV.
Coordinate with local authorities for appropriate delivery of TB and HIV
services.
6. Engage in
consultations for policy and guidelines development.

J. Development and other external partners shall:

L. Provide technical assistance in planning, implementing, capacity building,
monitoring, and evaluation.
2. Provide support for TB-HIV commodities and activities.
TX. FUNDING
’

The DPCB shall allocate funding through the Communicable Disease budget
line item for implementation of these guidelines.

SEPARABILITY CLAUSE

If any clause, sentence, or provision of this Order shall be declared invalid,

unconstitutional, illegal, or unenforceable, the other provisions not acted thereby shall
remain vital, valid, and effective.

REPEALING CLAUSE

The DOH AO No. 2008-0022 entitled “Policies and Guidelines in the

Collaborative Approach of TB and HIV Prevention and Control” and AO No.
2014-0005 entitled “Revised Policies and Guidelines in the Collaborative Approach
of TB and HIV Prevention and Control” and other issuances, rules and regulations
inconsistent with or contrary to this AO are hereby repealed, amended, or modified
accordingly.

Xi. EFFECTIVITY

This Administrative Order shall take effect after fifteen (15) days following its
publication in a newspaper of general circulation.

FRANCISCO 1Bier TI, MD, MSc

Secretary of Health

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